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Clinical Dermatology E-Book

Clinical Dermatology E-Book

Thomas P. Habif

(2009)

Abstract

Widely recognized as the world’s leading dermatology manual, the new edition of Habif’s Clinical Dermatology has been exhaustively updated to reflect today’s best practices. A wealth of new features makes it easier, than any other resource, to identify, treat, and manage the full range of skin diseases.

  • Presents outstanding photographs for virtually every common skin disorder.

  • Organizes disease information with a Disorders Index on the inside front cover, allowing for quick access to specific guidance, and a brand new Regional Diagnosis Atlas in chapter 1.

  • Uses a consistent format in every chapter to present information in a logical, easy-reference fashion.
  • Features extensive revisions throughout that highlight the newest developments in diagnosis and treatment, giving you the absolute latest on virtually every skin disorder.
  • Over 1000 full color photographs, incorporating 500 brand-new, never-before-published images for enhanced visual diagnostic guidance.
  • Offers expanded material on non-white skin that prepares you to diagnose and treat different patient populations.
  • Provides coverage of tropical diseases to help you treat patients who have been traveling abroad.

Table of Contents

Section Title Page Action Price
Front cover Cover
Disorders index IFC1
Quick reference formulary ii
Copyright vi
Front matter v
Clinical dermatology v
Preface vii
Rapid access to the text vii
PMID numbers (pubmed identification numbers) vii
Web-based text vii
Web-based formulary vii
Text organization and content vii
How to use this book vii
Students in the classroom vii
Students in the clinic vii
The non-dermatologist provider viii
The dermatologist viii
Images viii
Production viii
Table of contents ix
Skin anatomy xii
Chapter\t| 1 | Principles of diagnosis and anatomy 1
Skin anatomy 1
Epidermis 1
Dermis 1
Dermal nerves and vasculature 1
Diagnosis of skin disease 2
A methodical approach 2
Examination technique 2
Approach to treatment 2
Primary lesions 2
Secondary lesions 2
Chapter\t| 2 | Topical therapy and topical corticosteroids 75
Topical therapy 75
Emollient creams and lotions 75
Severe dry skin (xerosis) 75
Wet dressings 76
Topical corticosteroids 77
Strength 77
Megapotent topical steroids (group I) 78
Concentration.  78
Compounding.  78
Generic versus brand names.  78
Vehicle 78
Steroid-antibiotic mixtures 79
Amount of cream to dispense 79
Application 80
Frequency 80
Tachyphylaxis.  80
Intermittent dosing 80
Group I topical steroids.  80
Groups II through VII topical steroids.  80
Methods 80
Simple application.  80
Occlusion.  80
Method of occlusion.  80
Systemic absorption 82
Avoid weaker, “safe” preparations.  82
Children.  82
Adults.  82
Adverse reactions 82
Steroid rosacea and perioral dermatitis 82
Management.  83
Atrophy 85
Occlusion.  87
Mucosal areas.  87
Steroid injection sites.  87
Long-term use.  88
Alteration of infection 88
Tinea incognito.  88
Infestations and bacterial infections.  88
Contact dermatitis 90
Topical steroid allergy 90
Management.  90
Patch testing.  90
Glaucoma 90
Chapter\t| 3 | Eczema and hand dermatitis 91
Stages of eczematous inflammation 91
Acute eczematous inflammation 93
Subacute eczematous inflammation 94
Adult-onset recalcitrant eczema and malignancy 97
Chronic eczematous inflammation 98
Hand eczema 100
Irritant contact dermatitis 101
Atopic hand dermatitis 103
Allergic contact dermatitis 104
Nummular eczema 104
Lichen simplex chronicus 104
Recurrent focal palmar peeling 105
Hyperkeratotic eczema 105
Fingertip eczema 107
Pompholyx 109
Id reaction 109
Eczema: Various presentations 110
Asteatotic eczema 110
Nummular eczema 111
Chapped fissured feet 113
Self-inflicted dermatoses 115
Lichen simplex chronicus 115
Chronic vulvar itching 118
Red scrotum syndrome 118
Treatment.  118
Prurigo nodularis 119
Neurotic excoriations 120
Psychogenic parasitosis 121
Stasis dermatitis and venous ulceration: Postphlebitic syndromes 122
Stasis dermatitis 122
Types of eczematous inflammation 122
Subacute inflammation 122
Acute inflammation 122
Chronic inflammation 123
Treatment of stasis dermatitis 123
Topical steroids and wet dressings.  123
Venous leg ulcers 124
Management of venous ulcers 126
Initial evaluation and treatment.  126
Varicose veins.  126
Laboratory evaluation.  127
Function studies.  127
Treatment.  128
Leg elevation.  128
Inflammation surrounding the ulcer.  128
Systemic antibiotics.  128
Topical antibiotics.  128
Debridement of ulcer bed.  128
Wound debridement.  128
Occlusive dressings.  128
Chemical debridement.  128
Surgical or mechanical debridement.  128
Definitive treatment 129
Compression.  129
Compression bandages.  129
Graded elastic compression stockings.  129
Nonelastic bandages.  129
Pneumatic compression pumps.  129
Aspirin.  129
Pentoxifylline.  129
Vitamins.  129
Grafting.  129
Vein surgery.  129
Chapter\t| 4 | Contact dermatitis and patch testing 130
Irritant contact dermatitis 131
Allergic contact dermatitis 133
Phases 133
Sensitization phase 133
Elicitation phase 133
Cross-sensitization 133
Systemically induced allergic contact dermatitis 133
Clinical presentation 135
Allergic contact dermatitis in children 136
Management of allergic contact dermatitis 136
Rhus dermatitis 138
Natural rubber latex allergy 140
Types of reactions 140
Irritant contact dermatitis.  140
Allergic contact dermatitis (type IV allergy).  140
Chapter\t| 5 | Atopic dermatitis 154
Pathogenesis and immunology 156
Clinical aspects 156
Infant phase (birth to 2 years) 158
Childhood phase (2 to 12 years) 162
Adult phase (12 years to adult) 166
Associated features 167
Dry skin and xerosis 167
Ichthyosis vulgaris 167
Keratosis pilaris 168
Hyperlinear palmar creases 170
Pityriasis alba 170
Atopic pleats 170
Cataracts 170
Triggering factors 172
Temperature change and sweating 172
Decreased humidity 172
Excessive washing 172
Contact with irritating substances 172
Contact allergy 172
Aeroallergens 172
Microbic agents 172
Food 172
Emotional stress 172
Treatment of atopic dermatitis 172
Dry skin 174
Inflammation and infection 174
Pimecrolimus cream 1% (elidel) 175
Chapter\t| 6 | Urticaria and angioedema 181
Clinical aspects 182
Pathophysiology 185
Initial evaluation of all patients with urticaria 186
Acute urticaria 186
Chronic urticaria 188
Differential diagnosis 188
Treatment of urticaria 191
Approach to treatment 191
First-line therapy 191
Antihistamines.  191
Mechanism of action.  191
Initiation of treatment.  191
Side effects.  191
Long-term administration.  191
H1 and H2 antihistamines.  191
First-generation (sedating) H1 antihistamines.  191
Second-generation (low-sedating) H1 antihistamines.  191
Fexofenadine (allegra).  191
Cetirizine (zyrtec).  192
Loratadine (claritin).  193
Desloratadine (clarinex).  193
Tricyclic antihistamines (doxepin).  193
Epinephrine.  193
Second-line agents 193
Oral corticosteroids.  193
Leukotriene modifiers.  193
Dapsone.  193
Calcineurin inhibitors.  193
Third-line agents 193
Intravenous immunoglobulin.  193
Methotrexate.  193
Topical measures.  193
Physical urticarias 194
Dermographism 194
Pressure urticaria 196
Cholinergic urticaria 197
Exercise-induced anaphylaxis 198
Cold urticaria 198
Solar urticaria 199
Pathogenesis 199
Heat, water, and vibration urticarias 199
Aquagenic pruritus 199
Angioedema 200
Acquired forms of angioedema 200
Acquired angioedema (C1 INH deficiency syndromes) 204
Episodic angioedema-eosinophilia syndrome.  204
Hereditary angioedema 204
Contact urticaria syndrome 207
Pruritic urticarial papules and plaques of pregnancy 207
Urticarial vasculitis 209
Serum sickness 210
Mastocytosis 211
Spectrum of disease 211
Cutaneous mastocytosis 211
Solitary mastocytoma.  212
Urticaria pigmentosa.  212
Telangiectasia macularis eruptiva perstans (TMEP).  214
Diffuse cutaneous types.  214
Systemic mastocytosis 214
Diagnosis.  215
Diagnostic criteria for systemic mastocytosis.  215
Diagnosis. 216
Skin disease.  216
Blood and urine studies.  216
Prognosis.  216
Management. 216
Cutaneous disease.  216
Systemic disease treatment.  216
Reduce mast cell burden.  216
Chapter\t| 7 | Acne, rosacea, and related disorders 217
Acne 217
Classification 219
Etiology and pathogenesis 223
Approach to acne therapy 225
Initial visit 225
History.  225
Pathogenesis and course.  225
Acne and diet.  225
Cosmetics and cleansers.  225
Oral contraceptives.  225
Initial evaluation 225
Type of lesions.  225
Degree of skin sensitivity.  225
Selection of therapy.  225
Course of treatment.  225
Acne treatment 226
Comedonal acne 226
Clinical presentation.  226
Treatment.  226
Mild inflammatory acne 227
Clinical presentation.  227
Treatment.  227
Moderate-to-severe inflammatory acne 228
Clinical presentation.  228
Treatment.  228
Severe: Nodulocystic acne 230
Clinical presentation.  230
Cystic acne 230
Pyoderma faciale.  230
Acne fulminans 230
Acne conglobata 234
Treatment of nodulocystic acne 234
Therapeutic agents for treatment of acne 235
Retinoids 235
Tretinoin.  235
Tazarotene.  235
Adapalene.  236
Azelaic acid.  236
Benzoyl peroxide 236
Benzoyl peroxide/antibiotic formulations.  236
Principles of treatment.  236
Allergic reaction.  236
Drying and peeling agents 236
Topical antibiotics 237
Oral antibiotics 237
Mechanism of action and dosage.  237
Antibiotic-resistant propionibacteria and long-term therapy.  237
Long-term treatment.  237
Dosage and duration.  237
Tetracycline.  237
Dosing.  237
Adverse effects.  237
Doxycycline.  238
Chapter\t| 8 | Psoriasis and other papulosquamous diseases 264
Psoriasis 264
Pathogenesis 264
Clinical manifestations 265
Drugs that precipitate or exacerbate psoriasis 266
Lithium.  266
Beta-blocking agents.  266
Antimalarial agents.  266
Systemic steroids.  266
Comorbidities associated with psoriasis 267
Clinical presentations 267
Chronic plaque psoriasis 267
Guttate psoriasis 268
Generalized pustular psoriasis 269
Erythrodermic psoriasis 269
Light-sensitive psoriasis 270
Psoriasis of the scalp 270
Psoriasis of the palms and soles 270
Pustular psoriasis of the palms and soles 270
Keratoderma blennorrhagicum (Reiter syndrome) 272
Psoriasis of the penis and Reiter syndrome 273
Pustular psoriasis of the digits 273
Psoriasis inversus (psoriasis of the flexural or intertriginous areas) 274
Human immunodeficiency virus (HIV)–induced psoriasis 274
Psoriasis of the nails 275
Psoriatic arthritis 276
Defining PsA 276
Differentiating PsA and RA 279
Differentiating PsA from osteoarthritis (OA) and gout 279
Treatment of psoriasis 280
Topical therapy 282
Calcipotriene (dovonex) 282
Calcitrol (vectical) 282
Retinoids 282
Topical steroids 282
Intralesional steroids 283
Anthralin 283
Preparations and use.  283
Short-contact therapy.  283
Ultraviolet light B 284
Ultraviolet light B and lubricating agents.  284
Ultraviolet light B and systemic agents.  284
Narrow-band ultraviolet light B (NB-UVB).  284
Photochemotherapy 284
PUVA combined with other modalities.  285
PUVA plus acitretin.  285
Long-term side effects.  285
Skin tumors.  285
Lentigines.  285
Cataracts.  285
Short-term side effects.  285
Nausea.  285
Phototoxicity.  285
Tape or occlusive dressings 285
Treating the scalp 285
Removing scale.  286
Mild to moderate scalp involvement.  286
Treatment of diffuse and thick scalp psoriasis.  286
Tar and oil.  286
Anthralin.  286
Systemic therapy 286
Rotational therapy 286
Methotrexate (see boxes 8-2 to 8-10) 287
Indications.  287
Mechanism of action.  287
Dosing.  287
Monitoring.  287
Side effects.  287
Folic and folinic acid supplements.  287
Liver fibrosis, cirrhosis, and biopsy interval.  291
Liver biopsy.  291
Lung toxicity.  291
Recall of sunburn.  291
Pregnancy.  291
Drug interactions.  291
Retinoids 292
Acitretin.  292
Indications.  292
Dosing strategy.  292
Acitretin and ultraviolet light B and PUVA.  292
Laboratory changes.  292
Side effects.  292
Isotretinoin 292
Cyclosporine (see boxes 8-14 to 8-17) 294
Baseline monitoring.  294
Kidney function and creatinine.  294
Hypertension.  294
Liver function.  296
Other chemistries.  296
Other side effects.  296
Dosage.  296
Low-dose approach.  296
High-dose approach.  296
Intermittent short courses.  296
Response to treatment.  297
Contraindications.  297
Drug interactions.  297
Combination therapy.  297
Rotational therapy 297
Other systemic drugs for psoriasis 297
Biologic therapy for psoriasis 306
Vaccines 306
TNF-α inhibitors for the treatment of psoriasis 306
Adalimumab.  306
Etanercept.  306
Pediatric psoriasis.  307
Infliximab 307
Biologics that target pathogenic T cells 308
Alefecept.  308
Biologics that target cytokines interleukin (IL)-12 and IL-23 308
Pityriasis rubra pilaris 309
Seborrheic dermatitis 312
Infants (cradle cap) 312
Young children (tinea amiantacea and blepharitis) 312
Adolescents and adults (classic seborrheic dermatitis) 314
Acquired immunodeficiency syndrome 315
Treatment of seborrheic dermatitis 315
Shampoos.  315
Topical steroids.  315
Antiyeast medications.  315
Oral antifungals.  315
Other topicals.  315
Pityriasis rosea 316
Lichen planus 320
Localized papules 322
Hypertrophic lichen planus 322
Generalized lichen planus and lichenoid drug eruptions 322
Lichen planus of the palms and soles 322
Follicular lichen planus 322
Oral and genital lichen planus 324
Erosive vaginal lichen planus 324
Nails 325
Diagnosis 325
Treatment 326
Therapy for cutaneous lichen planus 326
Therapy of mucous membrane lichen planus 326
Lichen sclerosus et atrophicus 327
Pityriasis lichenoides 332
Grover’s disease 334
Chapter\t| 9 | Bacterial infections 335
Skin infections 335
Impetigo 335
Bullous impetigo 336
Clinical manifestations.  336
Nonbullous impetigo 338
Acute nephritis 340
Laboratory findings.  340
Prevention of impetigo 340
Recurrent impetigo 341
Treatment of impetigo 341
Oral antibiotics.  342
Mupirocin (bactroban).  342
Retapamulin (altabax).  342
Cellulitis and erysipelas 342
Diagnosis of cellulitis 342
Cellulitis vs. deep vein thrombosis.  342
Cultures.  343
Treatment of cellulitis 345
Adults.  345
Preventing recurrent cellulitis 346
Prophylactic antibiotics to prevent recurrence.  346
Children.  346
Cellulitis of specific areas 346
Cellulitis and erysipelas of the extremities 346
Chapter\t| 10 | Sexually transmitted bacterial infections 382
Sexually transmitted disease presentations 382
Genital ulcers 385
Developed countries 385
Syndromic management of sexually transmitted diseases 387
World health organization (WHO).  387
Venereal warts 395
Chemical (self-applied by patient) 395
Chemical (provider administered) 395
Physical 395
Vaginal warts 395
Cervical warts 395
Meatal and urethral warts 395
Syphilis 396
Incidence 396
Stages 396
Risk of transmission 397
T. pallidum 397
Primary syphilis 398
Secondary syphilis 400
Lesions 400
Latent syphilis 402
Tertiary syphilis 402
Syphilis and human immunodeficiency virus 402
Congenital syphilis 403
Early congenital syphilis 403
Late congenital syphilis 403
Syphilis serology 403
Venereal disease research laboratory and rapid plasma reagin tests 405
Quantitative testing.  405
False-positive reactions.  405
Prozone phenomenon.  405
Fluorescent treponemal antibody absorption and T. pallidum particle agglutination tests 405
Tests for neurosyphilis 406
Patients with human immunodeficiency virus 406
Treatment of syphilis 406
Jarisch-Herxheimer reaction 406
Management of the patient with a history of penicillin allergy 406
Posttreatment evaluation of syphilis 406
Serologic response to treatment 406
Late latent syphilis 407
Frequency of follow-up serologic tests 407
Reinfection in primary, secondary, and latent syphilis 407
Rare sexually transmitted diseases 408
Lymphogranuloma venereum 408
Primary lesions 408
Inguinal stage 408
Genitoanorectal syndrome 409
Diagnosis 409
Chlamydia tests.  409
Management 409
Drug regimen.  409
Lesion management.  409
Chancroid 410
Bacteria 410
Primary state 411
Lymphadenopathy 411
Diagnosis 411
Culture 411
Gram stain 411
Treatment 411
Granuloma inguinale (donovanosis) 412
Clinical presentation 412
Diagnosis 412
Treatment 412
Diseases characterized by urethritis and cervicitis 413
Gonorrhea 413
Neisseria gonorrhoeae 413
Genital infection in males 413
Urethritis.  413
Diagnosis.  413
Genital infection in females 414
Cervicitis.  414
Urethritis.  414
Bartholin ducts.  414
Diagnosis.  414
Pelvic inflammatory disease 414
Clinical presentation.  414
Chapter\t| 11 | Sexually transmitted viral infections 419
Genital warts 419
Human papillomavirus 419
Incidence 419
Transmission 419
Clinical presentation 420
Oral condyloma in patients with genital human papillomavirus infection 423
Pearly penile papules 423
Genital warts in children 424
Genital warts and cancer 424
Diagnosis 424
Treatment 424
Management of sexual partners 424
Pregnancy 425
Children 425
Patient-applied therapies 425
Imiquimod.  425
Podofilox.  425
Provider-administered therapies 425
Cryosurgery.  425
Surgical removal and electrosurgery.  425
Trichloroacetic acid.  425
Podophyllum resin.  426
Warning.  426
Alteration of histopathology.  426
5-fluorouracil cream.  426
Carbon dioxide laser.  427
Interferon alfa-2b recombinant (Intron A).  427
Bowenoid papulosis 427
Molluscum contagiosum 428
Clinical manifestations 428
Diagnosis 428
Treatment 430
Over-the-counter treatments 430
Curettage 430
Cryosurgery 430
Antiviral and immunomodulatory therapies 430
Cantharidin 430
Potassium hydroxide 430
Oral cimetidine 430
Laser therapy 430
Trichloroacetic acid peel 430
Genital herpes simplex 431
Prevalence 431
Risk factors 431
Rate of transmission 435
Previous herpes simplex virus type 1 infection 435
Human immunodeficiency virus infection 435
Primary and recurrent infections 435
First-episode infections 435
Signs and symptoms.  435
Recurrent infection 436
Clinical signs and symptoms.  436
Frequency of recurrence.  436
Anatomic site.  436
Asymptomatic transmission.  436
Asymptomatic shedding.  436
Prevention 437
Laboratory diagnosis 437
Polymerase chain reaction 437
Culture 437
Histopathologic studies 437
Serology 437
Subtyping 437
Herpes simplex virus type 1.  437
Type-specific serologic tests 438
Indications to test 438
Pregnant women.  438
Monogamous couples.  438
Diagnosis of recurrent genital eruptions.  438
Identifying herpes simplex virus as a risk factor for human immunodeficiency virus transmission.  438
Psychosocial implications 438
Treatment of genital herpes (CDC guidelines) 439
Drugs 439
First clinical episode of genital herpes 440
Cool compresses 440
Counseling 440
Recurrent episodes of herpes simplex virus disease 441
Daily suppressive therapy 441
Lubrication 441
Genital herpes simplex during pregnancy 441
Pregnancy complications 441
Prenatal screening and management 441
Prevention 441
Antiviral therapy 442
Viral cultures 442
Management at labor 442
Neonatal herpes simplex virus infection 442
Clinical signs 442
Diagnosis 442
Prognosis 443
Treatment 443
Acquired immunodeficiency syndrome 444
Human immunodeficiency virus pathogenesis 444
CD4+ T-lymphocyte destruction leads to infection 444
The initial human immunodeficiency virus infection 444
The evolution of disease 444
Progression to acquired immunodeficiency syndrome 444
Diagnosis 445
Viral burden 445
Assessment of immune status (CD4+ T-cell determinations) 445
Revised CDC classification and management 446
Incidence 446
Dermatologic diseases associated with human immunodeficiency virus infection 446
Chapter\t| 12 | Warts, herpes simplex, and other viral infections 454
Warts 454
Clinical infection 454
Immunologic response 455
Treatment 455
Warts: The primary lesion 456
Common warts 457
Treatment of recalcitrant warts 458
Imiquimod.  458
Apple cider vinegar.  458
Filiform and digitate warts 458
Flat warts 459
Plantar warts 460
Subungual and periungual warts 464
Molluscum contagiosum 465
Herpes simplex 467
Primary infection 467
Lesions 467
Recurrent infection 468
Oral-labial herpes simplex 469
Primary infection 469
Recurrent infection 469
Treatment.  469
Combination treatment.  471
Topical treatment.  471
Cutaneous herpes simplex 471
Eczema herpeticum 473
Varicella 474
Chickenpox in the immunocompromised patient 476
Chickenpox and HIV infection 476
Chickenpox during pregnancy 477
Congenital and neonatal chickenpox 477
Maternal varicella 477
First trimester.  477
Second trimester.  477
Near birth.  477
Laboratory diagnosis 477
Rapid PCR.  477
Culture.  477
Serology.  477
Varicella vaccine 477
Treatment 478
Acyclovir 478
Children and adolescents.  478
Adults.  478
Immunocompromised patients.  478
VZIG.  478
Gammaglobulin.  478
Herpes zoster 479
Herpes zoster after varicella immunization 483
Herpes zoster and HIV infection 483
Herpes zoster during pregnancy 483
Syndromes 483
Ophthalmic zoster 483
Clinical presentation.  483
Eye involvement.  484
Ramsay Hunt syndrome.  484
Sacral zoster (S2, S3, or S4 dermatomes).  485
Complications 485
Pain and postherpetic neuralgia.  485
Duration of pain.  486
Pathophysiology of pain.  486
Dissemination.  486
Motor paresis.  486
Encephalitis.  486
Necrosis, infection, and scarring.  486
Pregnancy 487
Differential diagnosis 487
Herpes simplex.  487
Poison ivy.  487
“Zoster sine herpete.”  487
Cellulitis.  487
Laboratory diagnosis 487
Varicella–zoster vaccine.  487
Treatment 487
Treatment strategy.  487
Topical therapy.  487
Antiviral drugs.  487
Topical acyclovir.  488
Valacyclovir (Valtrex).  488
Famciclovir (Famvir).  488
Oral and intravenous acyclovir.  488
Acyclovir-resistant infection.  488
Disseminated herpes zoster in the immunocompromised host.  488
Oral steroids.  488
Nerve blocks.  488
Treatment of postherpetic neuralgia 489
Chapter\t| 13 | Superficial fungal infections 491
Dermatophyte fungal infections 491
Tinea 495
Tinea of the foot 495
Clinical presentations.  495
Interdigital tinea pedis (toe web infection).  495
Two feet-one hand syndrome 496
Treatment.  496
Chronic scaly infection of the plantar surface.  497
Acute vesicular tinea pedis.  497
Pitted keratolysis 498
Tinea of the groin 499
Differential diagnosis 501
Intertrigo.  501
Erythrasma.  501
Treatment for tinea of the groin.  501
Tinea of the body and face 502
Round annular lesions.  502
Tinea corporis (tinea gladiatorum) 504
Deep inflammatory lesions.  504
Treatment.  505
Invasive dermatophyte infection.  505
Tinea of the hand 507
Tinea incognito 508
Tinea of the scalp 509
Organism and transmission.  509
Hair shaft infection.  509
Endothrix pattern of invasion.  510
Ectothrix pattern of invasion.  510
Microscopic patterns of hair invasion.  510
Clinical patterns of infection.  510
Trichophyton tonsurans 510
Four patterns of infection.  514
Noninflammatory black dot pattern.  514
Inflammatory tinea capitis (kerion).  514
Seborrheic dermatitis type.  515
Pustular type.  515
Differential diagnosis.  515
Id reaction to therapy.  516
Treatment.  516
Tinea of the beard 517
Superficial infection.  517
Deep follicular infection.  517
Treatment.  517
Treatment of fungal infections 522
Systemic agents (see tables 13-1 to 13-3) 522
Griseofulvin.  522
Adverse reactions.  522
Allylamines.  522
Terbinafine.  522
Indications.  523
Triazoles.  523
Itraconazole (sporanox).  523
Fluconazole (diflucan).  523
Ketoconazole (nizoral).  523
Candidiasis (moniliasis) 523
Candidiasis of normally moist areas 524
Vulvovaginitis 524
Vaginal discharge 524
Non–sexually-acquired discharge.  524
Bacterial vaginosis.  524
Sexually acquired discharge.  524
Syndromic management.  525
Optional tests.  525
Monilial vulvovaginitis 525
Clinical presentation.  526
Management.  526
Topical antifungal agents.  526
Oral antifungal agents.  527
Acute vaginal candidiasis.  527
Patient preference.  527
Partner treatment.  527
Side effects.  528
Pregnancy.  528
Recurrent (resistant) disease 528
Laboratory tests.  528
Treating resistant cases.  528
Resistant organisms.  529
Oral candidiasis 529
HIV infection.  529
Infants.  529
Adults.  529
Treatment 530
Fluconazole.  530
Itraconazole.  530
Clotrimazole (mycelex) troche.  530
Ketoconazole (nizoral).  530
Nystatin (mycostatin) oral suspension.  530
Candida balanitis 531
Treatment.  531
Candidiasis of large skin folds 532
Intertrigo 534
Diaper candidiasis 534
Treatment.  534
Differential diagnosis.  534
Candidiasis of small skin folds 535
Finger and toe webs 535
Angles of the mouth 536
Treatment.  536
Tinea versicolor 537
Pityrosporum folliculitis 540
Chapter\t| 14 | Exanthems and drug eruptions 541
Exanthems 544
Measles 544
Typical measles 545
Eruptive phase.  546
Management of measles 547
Vitamin A treatment.  547
Immunity.  547
Individuals exposed to disease.  547
Use of human immunoglobin.  547
Revaccination risks.  547
Pregnancy.  547
Hand-foot-and-mouth disease 547
Scarlet fever 549
Rubella 552
Erythema infectiosum (parvovirus B19 infection) 553
Roseola infantum (human herpesvirus 6 and 7 infection) 556
Enteroviruses: Echovirus and coxsackievirus exanthems 558
Kawasaki disease 560
Superantigen toxin-mediated illnesses 566
Toxic shock syndrome 566
Cutaneous drug reactions 568
Drug eruptions: Clinical patterns and most frequently causal drugs (box 14-6) 570
Exanthems (maculopapular) 570
Urticaria 574
Pruritus 574
Drug eruptions 575
Acute generalized exanthematous pustulosis 575
Acneiform (pustular) eruptions 575
Eczema 575
Fixed drug eruptions 576
Blistering drug eruptions 578
Erythema multiforme and toxic epidermal necrolysis 578
Exfoliative erythroderma 578
Lichenoid (lichen planus–like drug eruptions) 578
Lupus erythematosus–like drug eruptions 578
Chemotherapy-induced acral erythema 579
Pigmentation 579
Photosensitivity 580
Vasculitis 580
Lymphomatoid drug eruptions 580
Skin eruptions associated with specific drugs 580
Chapter\t| 15 | Infestations and bites 581
Scabies 582
Anatomic features, life cycle, and immunology 582
Anatomic features 582
Infestation and life cycle.  583
Immunology.  583
Clinical manifestations 583
Primary lesions 584
Burrow.  584
Vesicles and papules.  584
Secondary lesions 584
Distribution 586
Infants 586
The elderly 586
Crusted (Norwegian) scabies 587
Diagnosis 587
Burrow identification 587
Sampling techniques and slide mount preparation 588
Mineral oil mounts.  588
Potassium hydroxide wet mounts.  588
Adhesive tape.  588
Treatment and management 588
Permethrin 588
Lindane 588
Application technique for permethrin and lindane.  588
Benzyl benzoate 588
Crotamiton (eurax lotion) 588
Sulfur 589
Ivermectin (stromectol) 589
Eradication program for nursing homes 589
Management of complications 589
Eczematous inflammation and pyoderma.  589
Post-scabietic pruritus.  589
Nodular scabies.  589
Environmental management.  589
Scabies in long-term care facilities 589
Pediculosis 590
Biology and life cycle 590
Nits 590
Clinical manifestations 591
Pediculosis capitis 591
Pediculosis corporis 591
Eyelash infestation.  591
Pediculosis pubis 592
Diagnosis 592
Combing 592
Treatment 593
Head, body, and pubic lice 593
Permethrin.  593
Pyrethrin.  593
Malathion (ovide).  593
Others.  593
Lindane.  593
Ivermectin.  593
Trimethoprim/sulfamethoxazole (bactrim, septra).  593
Nit removal 593
Wet combing (bug busting).  594
Pomades.  594
Hot air.  594
Fomite control.  594
“No nit” policies 594
Eye infestation 594
Caterpillar dermatitis 594
Clinical manifestations 595
Distribution 595
Diagnosis 595
Treatment 595
Spiders 596
Black widow spider 596
Clinical manifestations 596
Treatment 597
Immediate first aid.  597
Antivenin.  597
Muscle relaxants.  597
Analgesics.  597
Brown recluse spider 598
Clinical manifestations 598
Management 599
Moderate to severe skin necrosis.  599
Dapsone.  599
Steroids.  599
Surgery.  599
Antivenin.  599
Ticks 600
Lyme disease and erythema migrans 600
Geographic distribution 600
Cutaneous manifestations 602
Borrelia lymphocytoma.  602
Acrodermatitis chronica atrophicans.  602
Erythema migrans.  602
Early and late disease.  602
Three stages of infection 602
Early localized disease (erythema migrans and flulike symptoms).  604
Early disseminated disease (cardiac and neurologic disease).  605
Cardiac disease.  605
Chapter\t| 16 | Vesicular and bullous diseases 635
Blisters 635
Autoimmune blistering diseases 635
Major blistering diseases 635
Classification 638
Epidermis 638
The basement membrane zone (see figure 16-2) 638
Basement membrane antigens and diseases.  638
Diagnosis of bullous disorders 638
Dermatitis herpetiformis and linear IgA bullous dermatosis 642
Gluten-sensitive enteropathy 644
Lymphoma 644
Diagnosis of dermatitis herpetiformis 644
Treatment 645
Bullae in diabetic persons 646
Pemphigus 647
Pathophysiology 647
Desmoglein 647
Dsg1 and Dsg3 autoantibodies.  647
Pemphigus vulgaris 647
Pemphigus foliaceus, IgA pemphigus, and pemphigus erythematosus 649
Pemphigus erythematosus 649
Pemphigus foliaceus 650
Fogo selvagem 650
Diagnosis of pemphigus 650
Treatment 651
Approach to treatment 652
Course and remission 652
Risk of relapse 653
Conclusions 653
Determining remission and when to stop treatment.  653
Pemphigus in association with other diseases 653
Drug-induced versus drug-triggered pemphigus 653
Paraneoplastic pemphigus (neoplasia-associated pemphigus) 654
Laboratory diagnosis of paraneoplastic pemphigus 654
Histologic studies.  654
Direct immunofluorescence.  654
Indirect immunofluorescence.  654
The pemphigoid group of diseases 655
Bullous pemphigoid 655
Localized pemphigoid 658
Diagnosis 659
Treatment 659
Plan of therapy.  659
Topical therapy 659
Oral cavity.  659
Eyes.  659
Intralesional therapy.  659
Systemic therapy 659
Dapsone.  659
Corticosteroids.  659
Immunosuppressive agents (adjuvant therapy).  659
Etanercept.  659
Antibiotics.  659
Surgical therapy.  659
Localized vulvar pemphigoid 660
Benign chronic bullous dermatosis of childhood 660
Herpes gestationis (pemphigoid gestationis) 660
Pemphigoid-like disease 661
Epidermolysis bullosa acquisita 661
Benign familial chronic pemphigus 662
Epidermolysis bullosa 664
The newborn with blisters, pustules, erosions, and ulcerations 665
Chapter\t| 17 | Connective tissue diseases 671
Autoimmune diseases 671
Connective tissue diseases 672
Diagnosis 672
Antinuclear antibody screening 674
Connective tissue laboratory screening tests 676
Lupus erythematosus 678
Clinical classification (tables 17-5 and 17-6) 678
Subsets of cutaneous lupus erythematosus 680
Chronic cutaneous lupus erythematosus (discoid lupus erythematosus) 682
Subacute cutaneous lupus erythematosus 684
Systemic lupus erythematosus 686
Overview of SLE 686
Definition.  686
Epidemiology.  686
Clinical presentation.  686
Laboratory findings.  686
Diagnosis.  686
Treatment.  686
Cutaneous disease 687
Other cutaneous signs of lupus erythematosus 688
Diagnosis and management of cutaneous lupus erythematosus 689
Neonatal lupus erythematosus 690
Drug-induced lupus erythematosus 691
Dermatomyositis and polymyositis 692
Polymyositis 692
Dermatomyositis 693
Scleroderma 700
Systemic sclerosis 700
Chemically induced scleroderma 700
Diffuse scleroderma 700
Initial signs and symptoms.  700
Skin.  700
Raynaud’s phenomenon.  703
Telangiectasias.  703
Gastrointestinal tract.  703
Lungs.  703
Kidneys.  703
Other organs.  703
Prognosis.  704
Crest syndrome 704
Diagnosis of diffuse scleroderma 704
Autoantibodies.  704
Other studies.  705
Office nailfold capillary microscopy 706
Normal.  706
Overlap syndromes (scleroderma, dermatomyositis).  706
Mixed connective tissue disease.  706
Lupus.  706
Treatment 706
Systemic therapy.  706
Management of cutaneous disease.  707
Localized scleroderma 707
Morphea (figure 17-33) 707
Laboratory diagnosis.  708
Biopsy.  708
Treatment.  708
Linear scleroderma 709
Laboratory.  709
Treatment.  709
En coup de sabre 709
Chapter\t| 18 | Hypersensitivity syndromes and vasculitis 710
Hypersensitivity syndromes 710
Erythema multiforme 710
Stevens-Johnson syndrome/toxic epidermal necrolysis spectrum of disease 714
Stevens-Johnson syndrome 715
Toxic epidermal necrolysis 717
Erythema nodosum 720
Vasculitis 722
Vasculitis of small vessels 726
Hypersensitivity vasculitis 727
Henoch-Schönlein purpura 730
Neutrophilic dermatoses 734
Sweet’s syndrome (acute febrile neutrophilic dermatosis) 734
Erythema elevatum diutinum 737
Pyoderma gangrenosum 737
Schamberg’s disease 740
Chapter\t| 19 | Light-related diseases and disorders of pigmentation 741
Photobiology 741
Sun-damaged skin 743
Suntan and sunburn 747
Sun protection 747
Polymorphous light eruption 750
Hydroa aestivale and hydroa vacciniforme 752
Porphyrias 754
Porphyria cutanea tarda 756
Treatment 758
Phlebotomy.  758
Chloroquine.  758
Pseudoporphyria 758
Erythropoietic protoporphyria 760
Phototoxic reactions 761
Photoallergy 764
Disorders of hypopigmentation 764
Vitiligo 764
Guidelines for the treatment of vitiligo 767
Children.  767
Adults.  767
Narrow-band UVB.   768
Response to treatment.  768
Photochemotherapy.  768
Topical therapy.  768
Immunomodulators.  768
Excimer laser.  768
Grafting and transplantation.  768
Systemic steroids.  768
Cosmetics.  768
Depigmentation of remaining normal skin.  768
Idiopathic guttate hypomelanosis 769
Nevus anemicus 770
Tuberous sclerosis 770
Pityriasis alba 771
Disorders of hyperpigmentation 771
Freckles 771
Lentigo in children 771
Lentigo in adults 771
Melasma 772
Café-au-lait spots 774
Diabetic dermopathy 775
Erythema ab igne 775
Chapter\t| 20 | Benign skin tumors 776
Seborrheic keratosis 776
Stucco keratoses 784
Skin tags (acrochordon) and polyps 784
Dermatosis papulosa nigra 786
Cutaneous horn 786
Dermatofibroma 787
Hypertrophic scars and keloids 788
Keratoacanthoma 790
Epidermal nevus 792
Nevus sebaceous 794
Chondrodermatitis nodularis helicis 795
Epidermal cyst 796
Pilar cyst (wen) 798
Senile sebaceous hyperplasia 799
Syringoma 800
Chapter\t| 21 | Premalignant and malignant nonmelanoma skin tumors 801
Basal cell carcinoma 801
Pathophysiology 803
Histologic characteristics 803
Clinical types 803
Management and risk of recurrence 808
Recurrent basal cell carcinoma 810
Clinical presentation 810
Histologic type.  810
Location.  810
Size.  810
Treatment of basal cell carcinoma 810
Actinic keratosis 812
Squamous cell carcinoma in situ 820
Bowen’s disease 821
Erythroplasia of Queyrat 823
Arsenical keratoses and other arsenic-related skin diseases 824
Squamous cell carcinoma 824
Leukoplakia 829
Verrucous carcinoma 830
Primary cutaneous lymphomas 831
Cutaneous T-cell lymphoma 832
Paget’s disease of the breast 843
Extramammary Paget’s disease 844
Cutaneous metastasis 845
Chapter\t| 22 | Nevi and malignant melanoma 847
Melanocytic nevi 847
Common moles 848
Management 850
Suspicious lesions.  850
Nevi.  850
Recurrent previously excised nevi (pseudomelanoma).  850
Nevi with small dark spots.  850
Special forms 850
Atypical nevi 856
Classification of atypical melanocytic nevi 857
Clinical classification 857
Clinical features of atypical moles 858
Morphology.  858
Surface characteristics.  858
Development and distribution.  858
Histologic characteristics.  858
Management.  858
Malignant melanoma 860
Superficial spreading melanoma 863
Nodular melanoma 866
Lentigo maligna melanoma 868
Acral-lentiginous melanoma 870
Benign lesions that resemble melanoma 871
Lesion examination 871
Observation plus magnification plus dermoscopy.  871
Screening for melanoma.  871
Management of melanoma 872
Biopsy 872
Histologic findings and progression 872
Radial growth phase tumors.  872
Vertical growth phase tumors.  873
Tumor thickness (Breslow microstage).  873
Ulceration.  873
Tumor thickness (Clark level).  873
Pathology report.  873
Mitotic rate.  873
Tumor-infiltrating lymphocytes.  873
Histologic regression.  873
Angiolymphatic invasion and angiotropism.  873
Special stains.  873
Surgical therapy 874
Excision after biopsy (resection margins) 874
Metastatic staging and prognosis 874
Sentinel lymph node biopsy.  874
Indication.  874
Procedure.  874
Elective lymph node dissection.  874
Initial diagnostic workup 874
Staging and prognosis 875
Staging for localized melanoma: Stages I and II 875
Melanoma thickness 875
Ulceration 875
Pathologic staging of lymph nodes 875
Follow-up examinations 879
Follow-up intervals 879
Medical treatment 879
Treatment of lentigo maligna 879
Dermoscopy 880
Chapter\t| 23 | Vascular tumors and malformations 891
Congenital vascular lesions 891
Hemangiomas of infancy 892
Superficial hemangiomas 892
Management 893
Nonintervention.  893
Treating ulcers and rapidly proliferating lesions.  893
Local wound care.  893
Infection.  894
Corticosteroids.  894
Intralesional steroids.  894
Lasers.  895
Topical imiquimod.  895
Surgery.  895
Interferon alfa-2b.  895
Deep hemangiomas 896
Kasabach-Merritt syndrome.  896
Hemangiomas associated with congenital abnormalities.  896
Malformations 898
Nevus flammeus (port-wine stains) 898
Systemic syndromes.  898
Sturge-Weber syndrome.  902
Klippel-Trénaunay syndrome.  902
Treatment.  902
Lasers.  902
Cosmetics.  902
Salmon patches 902
Acquired vascular lesions 904
Cherry angioma 904
Angiokeratomas 904
Venous lake 905
Lymphangioma circumscriptum 905
Pyogenic granuloma (lobular capillary hemangioma) 906
Bacillary angiomatosis 906
Kaposi’s sarcoma 907
Telangiectasias 910
Spider angiomas 910
Hereditary hemorrhagic telangiectasia 911
Scleroderma 911
Unilateral nevoid telangiectasia syndrome 912
Generalized essential telangiectasia 912
Chapter\t| 24 | Hair diseases 913
Anatomy 913
Physiology 915
Evaluation of hair loss 917
Generalized hair loss 920
Localized hair loss 922
Androgenetic alopecia in men (male pattern baldness) 922
Adrenal androgenic female pattern alopecia 924
Hirsutism 926
Alopecia areata 932
Prevalence 932
Clinical presentation.  932
Psychologic implications.  933
Nail changes.  933
Prognosis.  933
Differential diagnosis.  933
Etiology.  933
Immunologic factors.  933
Pathology.  933
Treatment.  934
Observation.  934
Topical steroids.  934
Intralesional injections.  934
Minoxidil (topical solution).  934
Anthralin.  934
Topical immunotherapy.  934
Systemic corticosteroids.  934
Cyclosporine.  934
Hair weaves and wigs.  934
Trichotillomania 936
Traction (cosmetic) alopecia 937
Scarring alopecia 938
Chronic cutaneous lupus erythematosus 939
Lichen planopilaris (figure 24-19) 940
Lichen planopilaris with frontal sclerosing alopecia 940
Pseudopelade (figure 24-20) 941
Folliculitis decalvans (figures 24-21 and 24-22) 942
Dissecting cellulitis (figures 24-23 and 24-24) 943
Acne keloidalis 944
Tufted folliculitis (figures 24-27 and 24-28).  945
Acne necrotica 946
Erosive pustular dermatosis 946
Trichomycosis 946
Chapter\t| 25 | Nail diseases 947
Anatomy and physiology 947
Normal variations 950
Nail disorders associated with skin disease 951
Acquired disorders 953
Bacterial and viral infections 953
Fungal nail infections 956
Treatment 959
Oral agents: Terbinafine, itraconazole, fluconazole.  959
Continuous terbinafine.  959
Prognostic factors.  959
Response to treatment.  959
Preventing recurrence.  959
Drug interactions.  961
Laboratory monitoring.  961
Safety of oral agents.  961
Recurrence rates.  961
Mechanical reduction of infected nail plate.  961
Surgical removal.  961
Nonsurgical avulsion of nail dystrophies.  961
Trauma 962
Onycholysis 962
Treatment.  962
Photoonycholysis.  963
Nail and cuticle biting 963
Nail plate excoriation 963
Hangnail 963
Ingrown toenail 963
Treatment 963
Ingrown nail without inflammation.  963
Ingrown nail with inflammation.  964
Recurrent ingrown nail.  964
Subungual hematoma 964
Nail hypertrophy 964
White spots or bands 964
Distal plate splitting (brittle nails) 965
Habit-tic deformity 965
Median nail dystrophy 966
Pincer nails (curvature) 966
The nail and internal disease 966
Color and drug-induced changes 969
Congenital anomalies 969
Tumors 970
Chapter\t| 26 | Cutaneous manifestations of internal disease 974
Cutaneous manifestations of diabetes mellitus 974
Necrobiosis lipoidica 974
Granuloma annulare 976
Acanthosis nigricans 978
Xanthomas and dyslipoproteinemia 980
Neurofibromatosis 983
Tuberous sclerosis 987
Internal cancer and skin disease 990
Cutaneous paraneoplastic syndromes 990
Familial cancer syndromes 990
Cowden disease (multiple hamartoma syndrome) 996
Muir-Torre syndrome 997
Gardner’s syndrome 997
Chapter\t| 27 | Dermatologic surgical procedures 999
Antibiotic prophylaxis 1001
Local anesthesia 1001
Hemostasis 1002
Wound healing 1002
Postoperative wound care 1005
Partial- and full-thickness open wounds 1005
Sutured wounds 1005
Office 1005
Home.  1005
Excess granulation tissue.  1005
Scarlet red gauze.  1005
Scar formation.  1005
Skin biopsy 1006
Punch biopsy 1006
Shave biopsy and shave excision 1006
Simple scissor excision 1008
Electrodesiccation and curettage 1009
Techniques 1009
Curettage 1010
Techniques—curettage 1010
Techniques—electrodesiccation and curettage of basal cell carcinoma 1010
Blunt dissection 1011
Technique 1011
Cryosurgery 1012
Technique 1012
Extraction of cysts 1013
Technique 1013
Mohs’ micrographic surgery 1014
Technique 1014
Chemical peels 1015
Dermal and subdermal fillers 1016
Liposuction 1016
Lasers 1016
Intense pulsed light 1018
Botulinum toxin 1018
Appendix A Bioterrorism 1019
Appendix B dermatology and the recently returned traveler 1024
Index I-1
A I-1
B I-4
C I-5
D I-7
E I-8
F I-9
G I-10
H I-11
I I-13
J I-14
K I-14
L I-14
M I-16
N I-18
O I-19
P I-20
R I-23
S I-24
T I-27
U I-28
V I-29
W I-29
X I-30
Y I-30
Z I-30